October 18, 2010

These Healing Hands

It's a reality in medicine that sometimes your patients die, and patients generally do not take exception to this fact if they happen to be cared for by a medical student. Some deaths can be more difficult than others as a student, depending on how well you got to know the patient beforehand or the circumstances of their death. Throughout my third year of medical school, I had several patients who I was caring for pass away while I was on service. Generally, these deaths were of one of two varieties:
(1) A healthy individual crashes and burns, a code is called, and we try our damndest for hours to fight the inevitable tide of death. Eventually the code is called, the team collapses in exhaustion, but there is a certain amount of solace to be taken in knowing that we tried everything.

(2) An individual with end stage x disease, who has been playing ding-dong-ditch at Death's front door for far to long, finally catches Death as he/she is walking by the front door in a bath robe and passes quietly in the night. News of these deaths comes during the AM handoffs and is generally met with a general sense of "Damn." but part of your psyche had already begun stacking the sandbags, knowing full well that your dying patient was, well, dying.

I had another, unique experience with death while on my neurology rotation. We had been consulted on an elderly woman admitted with altered mental status, in the classic CYA consult "rule/out stroke" that elderly patients with AMS tend to collect as they pass through the ED. I originally went to examine her with my attending in the AM, to find a frail looking woman, eyes open staring directly at the ceiling, unresponsive to anything in the room around her. She was altered (frankly, encephalopathic), but we did a full exam anyways and determined that she most likely did not have a stroke. Her breathing was shallow, raspy, and moist, a death gurgle of sorts as she was having difficulty handling her secretions. Labs would show a CO2 of >150... the likely culprit of her current stuporous state.

We weighed in our opinion and were off to clinic for the day. When the late afternoon rolled around, I decided to check back up on her, anticipating that after the requisite therapy for her COPD exacerbation, she would be doing much better. Luckily, I decided to glance at the chart before entering the room, and found a note from the medicine team "Discussed situation and prognosis with family. Family wishes DNR/DNI, palliative care consult."

I enter to find her much as she was that morning. Eyes open, staring blankly at the ceiling, still unresponsive. The late afternoon tends to be quiet in this wing of the hospital, and it was just her and I and the setting sun through the hospital window. Her raspy breathing penetrated harshly through the serenity of the moment. Like a good medical student, I set to task repeating the neurological exam, looking for any differences from the morning. Dolls eye test. Corneal reflex. Tap on the tendons. Check tone. It is just as I remove her sock to perform a babinski exam that I notice a subtle change in the room. It takes me a moment to realize that the throaty death rattle, my patient's weakened attempts at oxygen exchange... had stopped.

The first thought to race across my mind was "Oh shit!" I don't know how, but I remembered at that moment her do-not-resuscitate status, which fortunately prevented me from running into the hallways like an idiot yelling "Call a code!!!!" I watched as the color rapidly drained from her face, and stepped out of the room to talk to the nurse. "Ms. R just passed away. I don't know the protocol for the hospital, do you need to page the attending? I'm just a medical student." She replies that it is ok, as the patient was on comfort care. "Just go listen to the heart and lungs to confirm."

As a medical student, you are not trusted to do a whole lot. In today's chaotic environment of CYA-medicine and medical malpractice, we mainly pretend we can do things while someone holds our hand, until intern year rolls around. And a task as simple as listening to a patient's heart & lungs and feeling for a pulse should be elementary for a fourth year medical student, who has felt hundreds of pulses and listened to hundreds if not thousands of hearts. Regardless, there was a certain amount of anxiety involved in confirming a patient's death. Placing a finality on a life, even a life known to be near it's end, felt like a heavy responsibility. "I'm just a medical student."

"Time of death 18:21."

There would be no code, no crowd of people in the room, no blood staining the gown from STAT blood draws. Just myself, and my patient - a patient I had never even talked to. This was a different death than what I was used to. Some would say a good death. But the intimacy of the moment, especially considering it happened while I was performing the physical exam, struck me.

I page my neuro attending to tell him the news. He breaks the mood with some levity: "Well don't go see of the other patients now... I thought they were supposed to be healing hands!"

I looked down at those healing hands.


Anonymous said...

Your account of being present when your patient died in peace is very sincere and philosophical. You do indeed, have "healing hands".

rlbates said...

Ah, but because you went back to check on her, she was not alone when she died. She was in "healing hands."

Anonymous said...

That's some pretty legit writing right there...and I don't give out that complement lightly